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DES MOINES, Iowa (AP) - A hospital association estimates a Republican-backed plan to replace the Affordable Care Act could leave up to 250,000 Iowans without health insurance, and others speculate the change could destabilize the entire Medicaid system that serves poor and disabled people.

Gov. Terry Branstad has reiterated his support for repealing the ACA, but his office and the state agency that oversees health care in Iowa said an analysis of what the overhaul would mean to the state would need to wait until Congress approves a bill.

That hasn’t stopped health care groups in Iowa from trying to figure out how the measure would affect the people they represent. The nonpartisan Congressional Budget Office has estimated that 24 million Americans covered by Medicaid or who buy policies in the insurance marketplace will lose health care coverage over the next decade under the proposal.

The Iowa Hospital Association, which represents 118 hospitals, has estimated through statistical data that between 200,000 and 250,000 Iowa residents will lose coverage. Kirk Norris, president and CEO of the association, said the bill would cause people to lose preventive care coverage, increasing emergency room visits and leading to more costs for hospitals.

“Access through that system that we have today, which is a very strong primary care system led by hospitals, will erode, and it will probably erode substantially first in rural Iowa,” he said.

Ben Hammes, spokesman for Branstad and Lt. Gov. Kim Reynolds, the incoming governor, declined to comment on the association’s estimate.

AARP Iowa, which has 380,000 Iowa members age 50 and older, said the bill could jeopardize the Medicaid system, which provides health care coverage to children, low-income individuals, nursing home residents and people with disabilities. Roughly 609,000 people in Iowa receive services from the federal-state program, according to the nonpartisan Legislative Services Agency. A little over 154,000 joined in recent years after the state expanded eligibility under the ACA.

The GOP legislation in its current form would remove the expansion’s unique federal matching system in 2020 and separately cap spending for the overall Medicaid program based on enrollees. The current law offers unlimited federal funding that accounts for rising health care costs.

AARP Iowa spokesman Anthony Carroll said the 2020 changes mean 150,000 Iowa residents could face setbacks - either through reduced services or eligibility. That could also apply to the other Medicaid recipients because of the possible ripple effect of less federal funding. He also said the bill will have negative effects on Medicare, the separate federal health insurance program for people age 65 and older. And there’s concern over the burden on older Americans who may need to spend more to participate in the insurance marketplace.

The Congressional Budget Office estimates a reduction of $880 billion in federal Medicaid spending over the next decade if the expansion rollback and lower federal payments hold up.

“A lot of different facets to this bill,” Carroll said. “A lot of reasons why we oppose this.”

Iowa’s Medicaid program costs about $4 billion, of which the state pays about $1.4 billion, according to LSA. The Republican proposal to cap federal Medicaid funding could mean Iowa will eventually be on the hook for hundreds of millions of extra dollars for health care, potentially blowing a hole in Iowa’s budget.

If the state doesn’t pay, patients or doctors would foot the bill in some way. That’s worrisome to the Iowa Medical Society, which represents 6,200 physicians, doctors in training and medical students.

“Our advocacy is for the doctor-patient relationship and our role in that relationship,” said Dr. Paul Mulhausen, the organization’s president. “If our patients can’t get the care they need, we can’t help them to the extent we’re able to.”

Still, the concrete implications for Iowa are unclear while the federal legislation is being debated, according to Amy McCoy, spokeswoman for the Iowa Department of Human Services.

“Once a bill is passed, we analyze how it will impact our agency’s programs,” she said in an email, adding, “The Department will notify members if there are changes that impact their Medicaid coverage.”

Iowa has already undergone major changes in how it distributes Medicaid, with three out-of-state companies last year taking oversight of the program from the state. It’s unclear how that dynamic will play out.

It’s also possible there will be changes to the GOP bill, as all Democrats and some Republicans in Congress have expressed reservations.

Hammes, with the governor’s office, said Iowa residents expect Congress and President Donald Trump to repeal the Affordable Care Act, dubbed Obamacare.

“We are encouraged Congress is taking the first steps to replace Obamacare and look forward to working with Congress and the Trump Administration on a health care system that better serves Iowans,” Hammes said in a statement.

“The true reality about what’s being proposed at the national level is that it’s going to be devastating for Iowans,” he said. “Either by throwing hundreds of thousands of Iowans off their health care or severely limiting the health care for hundreds of thousands of Iowans. Or by costing the state of Iowa hundreds of millions of dollars. Or both.”